The Implications of The New Normal

We keep seeing articles and essays nowadays about the impact of multimorbidity.

It affects many people in the population, it is a major determinant of higher care costs and risks, and it isn’t just something that happens to the old.

And as a quick Google will show, the recurring phrase is that multimorbidity is the ‘New Normal’.

Which I suspect means that there has been a paradigm shift in our thinking about care – either completed or still in progress, which considers care for multimorbid populations alongside – and in some cases instead of – the management of individual diseases.

To some out there this language may begin to ring bells: there are echoes in this language of Thomas Kuhn’s landmark 1962 book The Structure of Scientific Revolutions. He famously argued that periods of discovery by accumulated knowledge – of ‘normal’ science – were periodically interrupted by more radical discoveries – which changed the ‘paradigm’ of knowledge against which science was done.

There have been lots of challenges and modifications to Kuhn’s ideas, of course, since 1962. But I think his work can still offer insights, if we accept that something of a revolution in the way we think about chronic conditions.

For example, he suggests that new paradigms can be used to revisit old data, and gain new insights. And that new paradigms also open up new conceptual spaces to be explored (rather like Halley explored the space opened up by Newton’s theories of gravity to predict the period of the comet that bears his name). New avenues of research are explored as a result of the new key insight.

And we can see some of that happening now. Recent papers we have seen considered the implications that multimorbidity has for:

  • Clinical staff development and medical education;
  • our understanding of the impact of deprivation;
  • polypharmacy management and minimally-disruptive medicine (one aspect of the ‘treatment burden’);
  • patient safety failures, including falls;
  • computerised medical records, standards and systems, and
  • the patient experience of care.

And this is a highly selective, incomplete list.

Commissioners and policy-makers also recognise the new paradigm. Multimorbidity is already beginning to feature in discussions of capitated budgets, and new, innovative contracting models like Commissioning for Outcomes will begin to focus on outcomes for patients with multiple conditions. And if multimorbidity is the new normal we can see that QOF – much of which is based upon the management of a select few long-term conditions – will also need a major review.

A paradigm shift indeed.